2.nursing module 2

TUBERCULOSIS CASE MANAGEMENT FOR NURSES

FUNDAMENTALS OFTUBERCULOSIS CASEMANAGEMENT

INTRODUCTION............................................................................................................................1

LEARNING OBJECTIVES ...............................................................................................................2

OVERVIEW OF CASE MANAGEMENT .........................................................................................3• Background .............................................................................................................................3• Definition.................................................................................................................................3• Goals and Principles of Case Management ..............................................................................4

TUBERCULOSIS NURSE CASE MANAGEMENT ...........................................................................5• Role of the Nurse Case Manager .............................................................................................5• Goals of Case Management in Tuberculosis .............................................................................6

ELEMENTS AND ACTIVITIES OF THE CASE MANAGEMENT PROCESS .....................................7• Case finding ............................................................................................................................7• Assessment ..............................................................................................................................8• Problem identification ............................................................................................................12• Plan development ..................................................................................................................14• Implementation......................................................................................................................15• Variance analysis ....................................................................................................................17• Evaluation ..............................................................................................................................18• Documentation ......................................................................................................................19

REVIEW QUESTIONS ..................................................................................................................21

APPENDIX 1: PATIENT EDUCATION DOCUMENTATION FORM................................................22

(continued)

MODULE 2

APPENDIX 2: EXAMPLES OF INTERMEDIATE OUTCOMES IN TB CASE MANAGEMENT........23

APPENDIX 3: EXAMPLES OF EXPECTED OUTCOMES IN TB CASE MANAGEMENT................25

APPENDIX 4: ELEMENTS OF A TREATMENT PLAN FOR PATIENTS WITH TB ..........................27

APPENDIX 5: TB CASE MANAGEMENT GUIDELINES FOR PATIENTS WHO REQUIREHOSPITALIZATION DURING OUTPATIENT TB TREATMENT................................28

APPENDIX 6: CHART REVIEW....................................................................................................30

REFERENCES ...............................................................................................................................31

BIBLIOGRAPHY...........................................................................................................................32

FUNDAMENTALS OF TUBERCULOSIS CASE MANAGEMENT: SELF-STUDY MODULE NUMBER 2 1

INTRODUCTION

This module provides an overview of case management, including historical background and defi-nitions. The principles and goals of the case management process are described, as well as acomparison of the roles and responsibilities of case management to the nursing process.

The concepts and principles of case management are applied to ambulatory care treatment ofpersons diagnosed or suspected of having clinically active tuberculosis (TB). Since tuberculosis istransmitted by droplet nuclei from an infectious person with active TB, the risk to the public’shealth cannot be ignored. Therefore, tuberculosis case management not only involves managingthe services required for patient care and treatment, but also includes an array of public healthactivities to help prevent and control the spread of the disease in the community.

The role of the nurse in TB case management is described along with specific goals that providedirection for the case management process. The process including eight elements and activitiesnecessary to achieve effective, efficient outcomes, is discussed in detail. Although Module 4 willaddress special issues related to the child with TB, there are instances when the case managementactivities for children are modified or affected in some way. In this module, issues particular to chil-dren will be italicized and found at the end of the paragraph.

Before reading this module, it is important for the nurse to demonstrate knowledge of TB patho-genesis, transmission, diagnosis, treatment, infection control practices, contact investigationprinciples and standards, and delinquency control procedures. The CDC Self-Study Modules onTuberculosis, 1-9 are a useful resource for providing this essential foundation (Centers for DiseaseControl and Prevention [CDC], 1995 & 1999).

2 FUNDAMENTALS OF TUBERCULOSIS CASE MANAGEMENT: SELF-STUDY MODULE NUMBER 2

LEARNING OBJECTIVES

After completion of this learning module, you will be able to:

1) Describe the history of case management

2) Define case management

3) Compare the case management process to the nursing process

4) Describe the role of the TB nurse case manager

5) Specify three goals of TB nurse case management

6) List the eight elements of the case management process

7) Identify components of the initial assessment and continual assessment

8) Explain how the assessment of a child differs from that of an adult patient with TB

9) State the two components of a nursing diagnosis

10) List three expected outcomes that should be included in the planning process

11) Identify activities for implementing TB case management

12) Explain how variance analysis is used in the TB nurse case management process


OVERVIEW OF CASE MANAGEMENT

BACKGROUNDCase management may seem like a relatively new concept, but its roots can be traced back as faras 1863 when Massachusetts founded a board of charities to coordinate services for the sick andpoor (Weil & Karls, 1985). Since that time, case management has been utilized by a variety ofdisciplines to coordinate health and human services and to help contain the costs of these services.However, the emphasis of this self-study module is the manner in which the nursing professionhas employed the process.

Initially, case management services were primarily community-based (Kalisch & Kalisch, 1996). Ashift to the acute care setting did not occur until the early 1980s with the establishment ofDiagnostic Related Groups (DRGs) and reimbursement incentives for shorter hospital stays.Hospitals employed nurse case managers to coordinate care and to facilitate patients’ transitionback into the community after discharge. The insurance industry and health maintenance organi-zations (HMOs) soon followed, recognizing the benefits of the case management process incoordinating services.

Presently, nurse case managers can be found in all areas of the nursing profession. Although thespecific implementation of the process may vary from setting to setting, the goals remain thesame; to provide quality health care and contain costs for the care provided.

DEFINITIONDuring the last decade, case management has been defined in a variety of ways. The Commissionfor Case Manager Certification (CCMC) defines case management as “a collaborative process thatassesses, plans, implements, coordinates, monitors, and evaluates the options and servicesrequired to meet an individual’s health needs, using communication and available resources topromote quality, cost-effective outcomes” (Kenyon et al, 1990). The American Nurses Association(1998) defines case management as a system of healthcare delivery designed to facilitate achieve-ment of expected outcomes within an appropriate length of stay. In Clinical Pathways forCollaborative Practice, the authors define case management as, “a practice model that uses asystematic approach to identify specific patients and manage patient care to ensure optimaloutcomes” (Ignatavicius & Hausman, 1995).

Case management is a system of healthcare delivery in which an individualized treatment plan forthe patient is developed by a multidisciplinary team to achieve established patient care outcomes.It is a recognized competency with established practice standards. As a competency, it is “the abil-ity to establish an appropriate plan of care based on assessment of the client/family and tocoordinate the necessary resources and services for the client’s benefit” (Conti, 1998). In thebroadest sense, case management can be described as a strategy that tailors a complex, frag-mented healthcare system for both the patient and provider’s benefits. In summary, casemanagement is efficient coordination of healthcare services to achieve specific and measurableoutcomes. It has the potential to influence the quality of patient care in a positive way, whilecontaining healthcare costs.


Goals and Principles of Case Management

• Provision of quality health care along a continuum

• Reduction of fragmented services across multidisciplinary settings

• Enhancement of the patient’s quality of life

• Achievement of anticipated outcomes

• Effective utilization of patient care resources

• Provision of cost effective health care

The case management process and the nursing process are similar and, in many situations, may beused interchangeably. Nurses are ideal case managers because of their familiarity with the nursingprocess. Furthermore, patient care always takes place in a system of health care in which nursesplay an essential role.

In both the nursing process and case management process, conclusions about the patient arebased on assessment data, and the identification of patient problems and plans for interventionsare the priority. In case management, strategies are developed and assessments are validated withthe interdisciplinary team. Although the case manager may not be involved in the provision ofdirect care, assurance that the plan of care is implemented is a major responsibility. In the nursingprocess, evaluation includes analysis of conflicts or discrepancies in the plan of care that mayrequire adjustment. Documentation is an essential activity in every component of both processes,and it establishes the care plan as an internal standard by which the nurse and the interdisciplinaryteam are evaluated.

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TUBERCULOSIS NURSE CASE MANAGEMENT

ROLE OF THE NURSE CASE MANAGER

The role of the TB nurse case manager includes managing services for the individual diagnosed orsuspected of having TB, from initiation to completion of treatment, a change in the diagnosis, ordeath. Some TB programs/clinics may choose to include the management of individuals with latentTB infection, or old, healed TB.

The role of the TB nurse case manager requires a proactive approach in which potential or antici-pated problems are identified and appropriate measures are used to address these problemsbefore they develop. For example, the day before a scheduled clinic visit, the outreach staff shouldremind the patient of the appointment. If the patient is unable to keep the appointment, thenurse case manager should immediately schedule another date, to avoid the patient being labeled“delinquent”. Problems experienced by TB patients are frequently confounded by multiple vari-ables and it may be difficult to sort out and identify cause and effect of complex problems. Areactive approach usually requires more time and energy on the part of the case manager andothers involved in patient care.

The role of the nurse case manager may vary, depending on resources available in ambulatory clin-ics or health departments. In addition to case management responsibilities, the nurse may also bethe provider of care and be required to perform some or all of the TB control activities. In thesesituations, it is recommended that administrative oversight of the case management process beestablished to help ensure that all activities are completed, and intermediate and expectedoutcomes are achieved.


GOALS OF CASE MANAGEMENT IN TUBERCULOSIS

TB case management is directed towards accomplishing the following goals:

• All hospitalized patients diagnosed or suspected of TB disease receive continuity of care duringtransition from hospital to the outpatient setting without interruption in treatment or essentialservices

• Disease progression and drug resistance are prevented

• Each patient receives TB care and treatment according to published standards of care(American Thoracic Society/Centers for Disease Control and Prevention [ATS/CDC], 1994)

• An integrated, coordinated system of health care allows patients to experience TB care along acontinuum rather than in fragments

• Patients complete TB treatment within appropriate time frames and with minimal interruptionin lifestyle or work

• Transmission of tuberculosis within the community is prevented through effective contactinvestigations and delinquency control activities

• The patient/family/community is educated about TB infection, disease, and treatment

• Individuals diagnosed with clinically active or suspected TB are reported according to regula-tions, and TB control activities are implemented according to standards of CDC and state,regional, or municipal TB control programs

• Case managers participate in policy development within the healthcare system (at communityor state level) that positively affect clinical and TB control outcomes

• Case managers participate in studies to improve case management services and documenta-tion, enhancement of adherence, and TB nursing


ELEMENTS AND ACTIVITIES OF THE CASEMANAGEMENT PROCESS

Eight elements of the case management process have been identified: case finding, assessment,problem identification, development of a plan, implementation, variance analysis, evaluation, anddocumentation. The following section provides a discussion of each element and specific casemanagement activities that lead to the desired outcomes for the patient with tuberculosis. (Cesta,Tahan & Fink 1998).

Case findingCase finding is the early identification of the patient with TB to ensure that public health reportingregulations are upheld, and TB control activities can be initiated as soon as possible. The nursecase manager should be familiar with facilities or organizations that provide services to clients athigh risk of TB infection and disease. Liaisons with these facilities/organizations should be devel-oped and sustained.

Activities of case finding include:

• Communicate with healthcare providers. Communication, education, and networking withhospital infection-control practitioners and physicians are important because these activitieshelp ensure early notification of those suspected or diagnosed with TB. The nurse casemanager often acts as a resource for nurses and physicians as they identify TB suspects andactive cases of TB.

• Develop a system to track patients with TB who are hospitalized during outpatienttreatment. Their status should be monitored to prevent interruption in services after discharge.

• Ensure that all public health reporting regulations have been met and that essentialTB control activities are initiated. Essential TB control activities include the TB interview andcontact investigation. If the TB case is not reported in a timely manner, there may be missedopportunities for prevention of transmission and treatment of infection or disease.

• Ensure that a contact investigation is completed in accordance with state and localpolicy. Every attempt is made to identify the source case in cases of infectious or potentiallyinfectious TB.

There must be a sense of urgency when very young children (less than 4 years ofage) are household or close contacts of an infectious case, because these childrenare at particular risk of developing TB disease once exposed and infected.

• Provide education about TB infection and disease to healthcare providers in the commu-nity to increase the awareness of TB, especially in areas of high prevalence. A high level ofsuspicion on the part of healthcare providers will prevent delayed diagnosis and treatment aswell as misdiagnosis.

This is especially important in diagnosing children who do not present with theusual symptoms of TB, such as cough and night sweats. (See Module 4 for moreinformation regarding the diagnosis of TB in children).


Assessment

Assessment is the gathering of data that will form the basis for TB treatment and care. In the TBcase management system, many professionals are involved in patients’ care and contribute to thedata from which the initial assessments are formed. The nurse case manager will draw assessmentdata from many sources, including community agencies, primary care providers, schools, and otherhealthcare facilities. Each situation must be assessed objectively to determine the appropriatenessof the planned intervention.

When the patient with TB is a child, it is important for the case manager to involveboth the child and his/her family in the assessment process.

The initial assessment should occur during the patient’s hospitalization. Patients who are diag-nosed during a hospitalization will require discharge planning. The case manager should ensureappropriate discharge planning occurs for all patients with TB to prevent transmission in thecommunity and interruption in treatment.

Prior to the patient’s first visit to the physician/clinic after hospital discharge, the nurse casemanager should ensure that a copy of the patient’s hospital record and chest x-ray is available tothe treating physician. Without the hospital record, the physician may not be able to make thecorrect judgments in medical management. If the patient is not hospitalized, the initial assessmentshould take place at the first clinic visit or during a home visit. At some time during the patient’sTB treatment, a home visit is helpful. Information gathered at the patient’s home is often morerevealing than assessments performed in the clinical or health department settings and can lead toa more accurate understanding of the patient’s lifestyle.

Activities included in the initial assessment:

• Obtain or review demographic information, including the name, address, telephonenumber(s), birth date, social security number, and name, address, and identifying informationof health insurance.

• Ascertain the extent of TB illness, including acuity and length of symptoms, bacteriologyand radiographic findings, laboratory analyses, tuberculin skin test results, nutritional status,vital signs, and baseline weight (without shoes and excess clothing). It is important to recordweight in kilograms. Temperature, pulse, and respiration should be assessed if the patientappears ill or the history suggests illness. Blood pressure evaluations are valuable, especially ifthe patient has no primary care provider.

In cases of pulmonary TB in children who are 6 years of age and under,anterior/posterior and lateral chest x-rays are important in the initial diagnosis.This is unlike adults who are suspected of TB or who are active cases. Theseadults usually need only an initial posterior/anterior chest x-ray.


• Obtain and review the patient’s previous health history to determine concurrent medicalproblems including HIV disease or risk factors, allergies, or medications that may interfere withTB drugs. It will be necessary for the case manager to obtain the names, addresses, and tele-phone numbers of the patient’s primary care provider and any specialists involved in his/hermedical care, previous hospitalizations, allergies, and current medications. It is important toknow the patient’s history of treatment for TB infection and/or disease, especially those whoare treatment failures or have relapse of TB disease as they are at a higher risk for developingmulti-drug resistant TB (MDR-TB).

It is also important to determine what the patient perceives as his/her most importantmedical/health problem. The date of the last menstrual period and contraceptive use shouldbe obtained from female patients.

• Determine infectiousness or potential infectiousness. This assessment should include theduration and frequency of symptoms, especially cough, and a review of the radiographic find-ings. If the patient is infectious or potentially infectious, the case manager should have anunderstanding of the period of infectiousness. The parameters of a contact investigation,including the need for repeating the tuberculin skin test for contacts who were initially nega-tive, can then be determined.

In the case of a child with TB who is 4 years of age or under, the contact investi-gation should focus on determining the source case of TB, since young childrencannot transmit TB. Dates of exposure and most recent information concerningthe infectiousness of the source case should be documented.

• Evaluate the patients’ knowledge and beliefs about TB, including a history of TB infamily and/or friends and the response to treatment. The nurse case manager can assess TBknowledge by interviewing the patient regarding TB transmission, pathogenesis, and symp-toms. Patient education should be based on current knowledge and ability to comprehendwritten, visual, and/or verbal information.

It is important to interview both the child and parent or guardian when assessingTB knowledge; however, adolescents should be given the opportunity to speak toa healthcare provider alone. Keep in mind that parents who have misinformation orcultural bias about TB may affect their children’s understanding of the disease.

Patient education can be documented on a form such as the one in Appendix 1.

• Monitor the TB medication regimen. The nurse case manager should ensure that medica-tions and dosages are prescribed according to ATS/CDC Treatment of Tuberculosis andTuberculosis Infection in Adults and Children (1994). If the initial assessment occurs during thepatient’s hospitalization, the case manager should ensure that the medications are given at thesame time every day, and that the ingestion of the medication is observed by a nurse. Thepatient’s tolerance to TB medications should be noted, and interactions with other medicationsshould be determined prior to the patient starting TB medications.

If TB medications are going to be given to a child in a school or day-care setting,parental authorization must be obtained.


• Identify barriers or obstacles to adherence in taking TB medications and keeping physicianor clinic appointments. This includes such issues as availability of transportation, the patient’spreferences for place and time of directly observed therapy (DOT), and the ability to swallowpills. Many adolescents and adults who have difficulty swallowing pills are embarrassed toreport this to the healthcare provider. It may be necessary to crush the pills and put them infood such as pudding or applesauce. In addition, the nurse case manager should determinethe need for enablers and identify incentives that will be most valuable to the patient.

When establishing school-based DOT, it is important to determine a time of daythat is most convenient and least disruptive to the school schedule.

• Review psychosocial status to identify unmet needs, the use of alcohol and/or illegal drugs,and any pre-existing psychiatric diagnoses. A good history of the patient’s social network isimportant to identify and document in the event that the patient does not return for follow-up. The nurse case manager needs to verify the patient/family’s address, evaluate residentialstability, and assess potential for homelessness. The patient’s residence(s) during the past yearshould be determined, particularly any congregate living situations, such as prison, jail, home-less shelter, nursing home, boarding home, or foster care. Occupation and/or student statusmust be established, and the name and address of business or school should be documented.Recent research involving DNA fingerprinting suggests that the usual criteria used to deter-mine close contacts of persons with infectious, active TB may not be sufficient. “Casualcontacts” may actually have had many hours of exposure to the source case of TB, and insome cases, transmission may have occurred with limited contact. In order to identify thosewho have shared common air space with the infectious, untreated patients withTB, it is neces-sary to have an understanding of the patient’s social and recreational activities and how he/shespends leisure time. This also includes time spent at faith-based functions.

The name and location of a child’s babysitter, daycare center or school should benoted.

An ongoing assessment takes place monthly either in an ambulatory clinic setting, healthdepartment, or private physician’s office. Additional assessments may need to be made throughoutthe month for patients experiencing problems in their TB treatment, or for those patients who arenonadherent to DOT or follow-up appointments.

Activities of the ongoing assessment include:

• Monitor the clinical response to treatment by reviewing vital signs, weight, bacteriologyreports, radiographic results, including drug sensitivities and TB symptoms and comparingthem to previous documented findings. This review is an important measurement of clinicalimprovement, worsening, or stabilization of the patient’s condition. If a variation is noted, thepatient should be interviewed to determine the potential cause(s) of the deviations(s). Allbacteriological reports should be listed in chronological order and correlated with the patient’scurrent symptom history and chest x-ray report to assure accuracy. Inconsistencies should trig-ger additional questions, such as the possibility of laboratory contamination, and should bebrought to the physician’s attention immediately.


• Determine HIV status and the risk factors for HIV disease, and refer the patient fortreatment, if indicated. It is important for patients to understand the correlation between TBand HIV disease. The nurse case manager should ensure that HIV counseling and testing aredone at the beginning of TB treatment, if the HIV status is not previously known. If the patientrefuses HIV testing, an assessment of the risk factors for HIV should be completed.

If the parents of a young child with TB refuse to permit the child to be HIV tested,the parents should be interviewed regarding the child’s risk of HIV disease, includingneonatal transmission.

• Review the treatment regimen to verify that the physician’s orders are clear and concise.One of the nurse case manager’s primary responsibilities is to ensure that the patientcompletes treatment according to the physician’s plan. It is also important to ensure that theplan is specific for the individual patient and follows the principles of TB treatment. Monitorside or adverse effects of medication. Review laboratory findings and contact the treatingphysician if abnormal results are obtained.

If the child is taking TB medications at school, regular communication with theschool nurse is indicated to determine whether the child is experiencing medicationside effects.

• Identify positive and negative motivational factors influencing adherence. Policies andprocedures must be in place to establish the expected monthly rate of DOT adherence. Anassessment of adherence needs to occur daily. If the nurse case manager is not involved inproviding the care, a notification system should alert him/her if the patient misses more than 2consecutive days of DOT, or there is suspicion of nonadherence in the case of self-adminis-tered therapy. A preventable interruption in treatment can be avoided if the nurse casemanager is notified immediately, rather than when the monthly DOT rate is calculated. Thenurse case manager should review the monthly adherence rate to ensure that all patients inthe cohort achieve the expected adherence rate. If the patient is self-administering TB medica-tion, a weekly visit should be made to the patient’s residence to assess adherence and observefor side effects or adverse reactions. The effectiveness of enhancement methods (i.e., incen-tives, enablers, behavioral contracting, or behavior modification) should also be regularlymonitored.

• Determine the unmet educational needs of the patient regarding transmission, diagnosis,and treatment of TB. Identify the concerns and anxieties regarding diagnosis, and need forfurther education. The educational needs of the patient/family may vary throughout the courseof treatment. Patient education will vary depending on beliefs about TB treatment, acceptanceof the diagnosis, coping mechanisms, cultural values, and the accuracy of the information theyhave already received. The nurse case manager should explore the effect the diagnosis has onthe patient’s relationships with other family members, co-workers, and social contacts so thatappropriate, culturally sensitive information can be provided.


• Review the status of the contact investigation, if one was conducted. It has been foundthat patients may not initially reveal the names of all close contacts. Over time, many moreindividuals are often identified. The following is an example that illustrates this clearly:

A 59-year-old male diagnosed with infectious, pulmonary TB receives his TB medicationsvia DOT at 9:30 AM Monday through Friday. After a contact investigation was performed,all identified contacts were tuberculin skin tested and medically evaluated. The clinic andTB control personnel considered the contact investigation complete. However, approxi-mately 4 months after the start of treatment a different staff member visited the patientfor DOT, covering for the regular outreach worker who was ill. The staff member arrived atthe patient’s home at 6:30 AM because it was on her way to work. Because she did nothave the patient’s phone number, she was unable to call ahead to explain the change inschedule. When she arrived, the patient was not there. His wife stated that he was atwork, babysitting for three young children from 6:30 AM to 8:30 AM every weekday forthe past 2 years. However, he had neglected to identify these children during the contactinvestigation in fear of alarming their parents.

There are countless stories from nurses and outreach workers reinforcing the fact that not all infor-mation is obtained from the patient/family at one time. Therefore, the nurse case manager mustensure that the list of contacts is updated from time-to-time and determine the need for furthertesting. It is also important to review the status of the contact investigation to ensure that time-lines and standards are followed. Checking for the accuracy of previous variables should occurthroughout the patient’s TB treatment.

Problem identificationIdentification of existing or potential problems is derived from the assessment. The problems maybe stated in the form of a nursing diagnosis or as a problem statement. The purpose of making anursing diagnosis is to identify patient problems for development of a treatment plan. The nursingdiagnosis must be within the scope of professional nursing practice; however, it may be comprisedof problems identified by various members of the multi-disciplinary team. For example:

Assessment data: Patient verbalizes very little understanding of TB disease, transmission, patho-genesis, and treatment.

Nursing diagnosis: Knowledge deficit related to lack of understanding of disease process andtreatment of TB.

In the above example, an outreach worker, during the TB interview process, obtained the data.Regardless of who collects data, the nurse case manager’s responsibility is to review and interpret thedata and document the assessment or identified problem (nursing diagnosis) in the medical record.

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Problem identification is not always easy. Confounding and conflicting variables presented bypatients often result in misleading conclusions. For example, the nurse case manager mightconclude that nonadherence was a problem because of the patient’s past history of leaving thehospital against medical advice and failure to keep clinic appointments. However, the reasons forthe patient’s previous behavior were never determined. Therefore, nonadherence may actually bethe result of a “real problem” that is yet to be identified. Until the actual reasons for the behaviorare determined, the nursing diagnosis for the previous nonadherence problem would be stated as,“the potential for continued infection and relapse related to patterns of nonadherence to TB treat-ment”. The plan of care would then be directed toward the nursing diagnosis rather than thenonadherent behavior.

Activities to identify problems include:

• Assess existing and/or potential health problems and document them using the nursingdiagnosis. A clear statement of the problems and possible etiologies is extremely important tothe case management process.

When the patient with TB is a child, the nurse case manager should remember toinclude the family system in identification of problems.

• Coordinate team meetings to discuss the patient assessment, antecedent variables, andidentified problems. It is important for the case manager to discuss the patient assessment andthe nursing diagnoses with team members. The team should agree on the conclusions drawnfrom the assessment and provide the nurse case manager with feedback. Both the patient andthe case manager benefit when the nursing diagnosis or problem is correctly identified andclarified for all members of the team. Errors in problem identification will lead to unsuccessfulinterventions and outcomes. Additional information that will be useful in planning patient carecan be obtained at team meetings. Team meetings are a good forum for discussing feelings orattitudes team members may have about patients or required tasks. The nurse case managershould use team meeting time to identify problems healthcare workers are experiencing, espe-cially those that may affect expected outcomes.

• Monitor the nursing diagnoses for appropriateness over time. This activity allows forchanges to be made as intermediate or expected outcomes are achieved, or as the patient’sstatus changes. New problems or changes will require the addition of new nursing diagnosesor a change in the existing ones.


Plan development

Planning begins when sufficient information has been gathered. Development of a plan is basedon assessment data and problems identified by members of the healthcare team. The plancombines both medical management of the patient and nursing interventions. Planning for contin-ued care of the patient with TB requires critical thinking and decision making and should alwaysinclude participation and commitment from all team members and the patient. Due to the lengthof TB treatment (from 6 to 24 months), the plan must include intermediate and expectedoutcomes. The nurse case manager is responsible for the overall plan including documentation,monitoring the patient response, interventions, intermediate and expected outcomes, and initiat-ing changes in the plan to reflect changes in circumstances (variances). The nurse case manageralso determines how the plan of care fits with the roles and responsibilities of the team membersdepending on their specific job descriptions.

In working with the pediatric population, the nurse case manager must ensure that thefamily and child are involved in the planning process. Gaining the cooperation of theparents and family is essential.

Plan development activities include:

• Establish the plan of care ensuring that all the components are included: assessments, nurs-ing diagnoses, required procedures such as x-rays, blood, sputum, auditory, visual acuity tests,medication orders, expected patient behaviors, TB control activities, and intermediate andexpected outcomes. The nurse case manager should ensure that the plan of care is useful andmeaningful. It becomes the internal standard of care for the patient as well as the performancestandard for the nurse case manager. Good planning will allow the patient to experience TBcare and treatment along the healthcare continuum and prevent duplication and fragmentationof services. The plan should be discussed and validated with all team members and the patient.

• Monitor the plan of care and patient response according to established time frames. It isimportant to pay attention to relevance of the information and the plan in view of the overallassessments. Each component of the plan should be reviewed to ensure that it is an accurateaccounting of the patient’s problems, required tests, and interventions. The achievement ofintermediate and expected outcomes should be documented. Examples of intermediate andexpected outcomes can be found in Appendix 2 and Appendix 3. This documentation willserve as the basis of the evaluation of services and analysis of variances.

• Negotiate and adjust the plan of care, as needed, to meet new realities. Since patientcircumstances are usually fluid and personnel resources often change over time, it is essentialthat the plan be negotiated with the patient and changed to adjust to new situations. Theplan should allow for flexibility and negotiation. The adjusted plan should be discussed withthe team members, as well as the patient.


Implementation

Implementation includes all the interventions required to move the TB patient along a coordinated,sequenced healthcare continuum from diagnosis to treatment completion and cure. The nursecase manager must ensure that all the Elements of a Treatment Plan for TB Patients (CDC, 1995)have been addressed in this implementation phase (see Appendix 4). Effective communication withall staff members is an essential component in successfully implementing a patient’s plan of care.Implementing the plan requires educating, coordinating, monitoring, locating, referring, negotiat-ing, documenting, decision-making, and advocating for the patient.

Implementation activities include:

• Monitor the patient’s response to TB treatment, interventions, and adherence. Thenurse case manager should ensure that the treatment is progressing according to the physi-cian’s plan, and that the patient continues to show signs of clinical improvement. Policies andprocedures regarding DOT and nonadherence will allow the nurse case manager to identifyevents that require additional assessment interventions. The nurse case manager should ensurethat the patient is informed about the consequences of nonadherence, including legal inter-ventions. Changes in the patient’s attitude towards the clinic and/or clinic staff should benoted and verified with the patient. Occasionally, a patient with TB may require hospitalizationduring the course of his/her treatment. This may or may not be TB-related. Regardless, it isimportant for the nurse case manager to monitor patient progress at frequent intervals toassure that TB treatment is provided according to standards of care and is not interrupted. Forspecific guidelines see Appendix 5.

Children’s clinical response to treatment may not be as significant as that of anadult. Therefore, it is important to reinforce what the expected response to treat-ment should be for the individual child during the course of treatment.

• Refer the patient to other healthcare providers, social service or community agenciesas needed. The nurse case manager should have a good understanding of the communityresources, including strengths and weaknesses. The referral process requires the case managerto locate and coordinate accessible, available, and affordable resources for the patient. Afterthe referral is made, the case manager should monitor the patient’s adherence to the referraland obtain the consultation or follow-up report in writing. Immediate intervention may benecessary if the patient or the referring agency experiences difficulty.

• Broker and locate needed services relating to the TB treatment. This may include labora-tory, auditory, or visual acuity testing, additional radiographs, or other tests required specificfor the patient. It is important to schedule or assist the patient in scheduling appointments,monitor the patient’s adherence to the appointment, and the results. An understanding of thepatient’s financial resources and health insurance coverage is important. Lack of financialresources or health insurance will affect the patient’s willingness to keep appointments, whichmay be critical to his/her health. The nurse case manager may need to discuss essential serv-ices with insurance companies or other healthcare providers to obtain the most cost effective,quality service.


• Negotiate a plan for DOT or self-administration evaluation. The nurse case managershould ensure the plan is suitable for the patient’s needs and achievable by the healthcareprovider(s). Due to the length of TB treatment, the patient’s circumstances may change. Thenurse case manager needs to verify that the time and place for DOT administration originallyagreed upon is still agreeable to the patient/provider. It also may be necessary to coordinatethe arrangements for DOT with outside organizations, such as school nurses, drug treatmentcenter nurses, etc.

• Coordinate strategies to improve adherence. Coordination helps to achieve the casemanagement goal of treatment completion and cure. The nurse case manager must haveknowledge of and proficiency in strategies to improve patient adherence. An understandingof the importance of developing and maintaining a therapeutic relationship with the patientthroughout the course of the TB treatment is critical. It is also important for the nurse casemanager to be familiar with the principles and practices of behavioral contracting and behav-ioral modification, two useful methods to improve adherence. Collaboration with teammembers is essential to obtain as much information as possible about strategies to improveadherence of individual patients and elicit opinions, attitudes, and feelings expressed by thepatient that may be counter productive to the goals. To be effective, incentives and enablersshould be meaningful and specific for a particular patient population.

To facilitate DOT adherence of children with TB, the nurse case manager needs tobe familiar with the childhood developmental stages, including important events,and utilize strategies in consideration of these stages (see Module 4, Table 5).

• Educate patient and caregivers about the TB disease process during the course of TBtreatment. Instruction should be relevant for the patient’s level of education or ability to learn.The nurse case manager should ensure that education is provided in the patient’s primarylanguage and is culturally appropriate. In addition, healthcare beliefs that are in conflict witheducational information should be identified and addressed.

Age-appropriate educational materials and methods should be utilized, especially inworking with children. When dealing with a school-aged child, it is important toexplain that TB is treatable, and with the adolescent, it may be necessary toconstantly reaffirm confidentiality.

• Advocate for the patient with team members and other service providers when necessary.The nurse case manager should demonstrate respect and understanding of the patient’scultural beliefs and values and prevent team members from imposing their own values orbelief systems on the patient. The nurse case manager should be able to communicate thepatient’s fear/anxieties, likes/dislikes, and needs/wants to the team members in a non-judg-mental manner. It is the nurse case manager’s responsibility to be a compassionate, caring,role model for the team so that the services and interventions can be planned and carried outfor the patient’s benefit. The case manager must also have an understanding of the teammembers, and mediate, negotiate, and resolve differences of opinion regarding the patientand interventions. Team building and conflict resolutions are important competencies requiredfor a successful nurse case manager.


• Monitor delinquency control activities to ensure that the patient and required activities areassigned to an outreach worker and completed according to established standards (e.g., anoutreach worker has 3 days to bring infectious TB patient to clinic). The nurse case managerneeds to have a good understanding of public health workforce skills and competencies inlocating and returning delinquent patients to TB treatment. It is also important to understandpolicies and procedures relating to delinquency control and to intervene at the administrativelevel if they are not in accordance with statewide standards.

Variance analysis

Variance analysis looks at the discrepancy between the anticipated and actual patient careoutcomes. Variances should not be considered failures but rather opportunities to improve thequality of care. They may arise from changes in the patient’s personal situation, medical condition,or healthcare resources. A flexible plan can easily be adjusted to accommodate variances. BecauseTB treatment takes 6 months or more, it is likely that the patient’s situation will change and vari-ances occur. If successful treatment outcomes are to be achieved in these new circumstances,changes in the care plan are necessary.

The nurse case manager should review all variances, make changes as necessary, and identify thefrequency of clinical, operational, or system problems. If variances are not addressed, the resultmay be feelings of frustration on the part of the patient and/or the healthcare team.

Variance analysis activities include:

• Identify variances in the plan of care at specified intervals to determine if intermediateand expected outcomes were achieved. The nurse case manager should review all assessmentsand information to determine if the outcomes are realistic.

• Describe the reason(s) for the variance. If reason(s) is unknown, conclusions regarding thevariance should be drawn based on assessments and critical thinking.

• Document the individual variances to identify changes that need to be made in thepatient’s plan of care. Often there are changes in the TB patient’s circumstances during thelengthy course of treatment. The following is an example of a variance:


The plan called for the patient to receive DOT in the clinic, Monday through Friday morn-ings. The patient routinely rode his bicycle to the clinic, and during inclement weather heused bus tokens to get to the clinic for DOT. His adherence had been 100% for the last 3months. During the last week, the patient was nonadherent. After 2 missed days of DOT,the case manager assigned an outreach worker to find the patient and determine thereason for the nonadherence. The outreach worker could not find the patient for 3 days.On the fourth day, the patient’s father was at home and informed the outreach workerthat the patient found a job at a construction site in another county. A van picked thepatient and his co-workers up every day at 7:30 AM and transported them to and fromwork. He returned home from work at approximately 7:30 PM. The outreach workerreported this to the case manager. The case was discussed during a team meeting. It wasdecided that a possible solution would be to place the patient on twice weekly treatment,since he was now sputum smear and culture negative and had completed 12 weeks ofDOT with excellent adherence. The outreach worker would visit the patient’s home eitherbefore 7:30 AM or after 7:30 PM. The patient would be consulted regarding this planprior to its implementation. The change to intermittent therapy was a benefit for theoutreach worker, clinic staff, and the patient as well.

Evaluation

Evaluation is an important component of the case management process. Throughout the evalua-tion process, the nurse case manager must demonstrate skills such as problem solving, criticalthinking, leadership, effective communication, negotiation, and networking. Evaluation is theoutcome of the case management process and should be continuous and ongoing. Patient care isnever complete without the evaluation component. In TB case management, the achievement ofdesired outcomes must be evaluated so that services and activities can be improved, and TB treat-ment goals achieved.

Evaluation activities include:

• Answers to the following questions:

Were the TB treatment plan and control activities implemented in a timely manner?

Were intermediate and expected outcomes achieved?

Was the patient satisfied with the services or care?

Were the nurse case manager and the team members satisfied with the plan and outcomes?

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• Monitor the multidisciplinary care plan at least monthly, or more frequently dependingon the complexity of treatment and patient variables. The appropriateness of interventionsshould be reviewed, as well as dates when intermediate and/or expected outcomes wereachieved. Attention should be given as to how rapidly the care plan was changed when theneed was identified. If the care plan has remained unchanged, the reason must be determine.An example of chart review is found in Appendix 6.

• Identify strengths or weaknesses in the healthcare system that negatively or positivelyaffect the expected outcome. A good evaluation will lead to positive changes for the patientand others.

• Conduct a cohort analysis at least quarterly to identify variances or common elementsamong the group. The nurse case manager, armed with variances common to the cohortpatients with TB, can make changes to prevent future variances from occurring with otherpatients.

• Monitor the regulatory reporting mechanism and the contact investigation to ensurethe TB case reports are accurate and updated according to state standards, and the contactinvestigation is complete.

Documentation

Documentation is an integral part of all steps in the case management process. Documentationchronicles patient-care outcomes and can be used to facilitate positive changes for both patientsand healthcare providers. The nurse case manager must ensure that documentation is completedregularly by all members of the multidisciplinary team. For example, if legal action is necessary toimprove adherence of a difficult patient, the outreach staff must have all attempts to locate andcommunicate with the patient explicitly documented. All interventions should be documented in aclear and concise manner to ensure continuation of appropriate care.

The nurse case manager should remember the cardinal rule of documentation: “If it isn’t docu-mented, it wasn’t done.” Training regarding documentation may be required for clinical and TBcontrol staff. The case manager must review the documentation to assure that it is consistent withboth external and internal standards. Proper documentation will enhance the continuity of care forpatients with TB, particularly if different providers are involved in the care over the course of treat-ment. See Module 1 for a discussion of documentation and the use of standardized nursing language.


Documentation activities include:

• Monitor the patient’s medical record at each clinic/physician visit, monthly, or morefrequently as indicated to ensure that all members of the multi-disciplinary team documentinformation and interventions/services/care when provided in a timely manner. This includeseducation and factors to improve patient adherence. Review the medical record for complete-ness, compliance with external and internal standards of care, and clarity. Ensure that allnecessary documentation from private physicians or referral agencies is included in thepatient’s record. Update the multidisciplinary care plan as required. Variances from the usualplan should be documented, including the reasons why the variances occurred and the ration-ale for the change in plan. Document the achievement of intermediate and expectedoutcomes as they occur.

• Document case management activities and elements of the case management processin the patient’s medical record. To be useful, documentation must be clearly and succinctlywritten. The use of a checklist will assist the nurse case manager to document patient care ina timely, efficient manner. For example, TB education can be documented using a format simi-lar to the patient education documentation form found in Appendix 1. Charting by exceptionis also another way to efficiently document assessments and interventions. Policies and proce-dures must be in place if charting by exception is used so that those standards of care areupheld.

• Assure patient confidentiality. The nurse case manager should inform the patient that themedical record is kept confidential. Written consent from the patient should be on file if it isnecessary to obtain or provide any part of the patient’s medical record with another provider,healthcare insurance agency, or community agency. It is also important to ensure that medicalrecords are not easily accessible to others during the day and are filed in a locked cabinet atthe end of the day.


REVIEW QUESTIONS

SECTION REVIEW – OVERVIEW OF CASE MANAGEMENT

1) What was the objective of early case management programs? 2) What prompted the rise of case management services in acute care settings?3) Define case management.4) List three goals of case management.5) List three principles of case management.6) Describe how the nursing process is similar to the case management process.

SECTION REVIEW–TUBERCULOSIS NURSE CASE MANAGEMENT

1) Identify the goals of nurse case management in TB.

SECTION REVIEW – ELEMENTS AND ACTIVITIES OF THE CASEMANAGEMENT PROCESS

1) Define case finding and explain the importance of identifying the source case.2) Name eight activities involved in the initial assessment process.3) Discuss ways to monitor the patient’s clinical response to treatment.4) Discuss the advantages of the team approach to problem identification.5) Describe how the nurse case manager involves team members in plan development.6) Name essential components of the implementation process and examples of each.7) Define variance analysis and how it relates to treatment care plans.8) Explain methods for evaluating patient care plans.9) Discuss the importance of documentation and name three case management activities

involved in the process.


APPENDIX 1PATIENT EDUCATION DOCUMENTATION FORM

PATIENT FACTORS THAT MAY AFFECT LEARNING (CHECK IF APPLICABLE) EVALUATION SCORE KEY

❐ Cognitive impairment ❐ Physical impairment 1 = Unable to Teach❐ Visual impairment ❐ Family dynamics 2 = Teaching Offered – Refused❐ Speech ❐ Hearing impairment 3 = Requires Reinforcement of Content❐ Primary language other than English ❐ Cultural/religious factors 4 = Demonstrates with Assistance❐ Literacy ❐ Emotional state 5 = Explains Independently❐ Readiness/motivation/desire to learn ❐ Other 6 = Demonstrates Independently

EXPECTED OUTCOMES TEACHING SESSIONS/LEARNER EVALUATION

Initials Evaluation

Initials Evaluation

InitialEvaluation

InitialsEvaluationPatient/family is able to:

Date Score Date Score Date Score Date Score

Verbalize an understanding that confidentiality will be maintained.

Verbalize understanding of the difference between TB infection and TB disease.

Verbalize understanding of TB transmission.

Demonstrate techniques to prevent transmission,e.g., proper use of mask, covering mouth and nose when coughing, correct use and disposal of tissues.Verbalize an understanding that TB is curable.

Verbalize an understanding of the consequences of not undergoing treatment for full length of time.

Verbalize an understanding of causes and consequences of MDRTB.

Agree to participate in DOT.

Verbalize an understanding that non-adherence can result in involuntary confinement.

Identify contacts.

Verbalize an understanding of the importance of knowing HIV status and its effect on TB treatment.


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APPENDIX 2EXAMPLES OF INTERMEDIATE OUTCOMES IN TB CASE MANAGEMENT

Activity: Initiate treatment with anti-TB medication• Appropriate TB regimen prescribed and DOT planned at first visit

Activity: Directly observed therapy (DOT)• DOT initiated within 1 working day• Compare patient’s monthly adherence rate to established objectives

Activity: Clinical monitoring of response to anti-TB treatment• Sputum conversion (smear) occurs within 2 to 3 weeks and sputum remains negative• Culture conversion within 8 to10 weeks, and culture remains negative• Clinical improvement subjectively and objectively noted in 80% of patients

Activity: Monitoring and follow up for TB drug side effects and adverse events• Side effects of medication will be minimized by adjusting method of ingestion• Baseline CBC, hepatic enzymes and platelet count obtained in 100% of patients placed

on four first-line drugs• Blood test repeated in 100% of patients who have abnormal test results, are at high risk

for side effects, or who present with signs or symptoms of adverse reactions to drugs• Baseline visual acuity and color vision (Ishihara) test performed at first visit on 100% of

patients taking ethambutol. Thereafter, repeated monthly• Baseline auditory and renal function studies performed on 100% of patients taking

capriomycin IM or IV• Baseline uric acid and hepatic enzyme levels obtained in 100% of patients taking PZA.

Repeated if abnormal or if symptoms of adverse reaction

Activity: Adherence monitoring• Continuity of TB treatment ensured by patient keeping monthly appointments• Barriers to adherence identified within 2 days of missed DOT and addressed within 3

working days

Activity: Insight into TB disease process• Education provided to 100% of patients and caregivers regarding pathogenesis, trans-

mission, and treatment of TB disease, the difference between latent infection anddisease, and prevention of transmission in the community


þActivity: Treatment plan documented• Individualized, multidisciplinary care plan developed during the first month of treatment

Activity: Community health*• TB interview conducted within 3 days after patient is reported as suspected of TB or

diagnosed as an active case• Identified contacts will be TB skin tested, if previously negative, within 15 days after

patient is reported as suspected of TB or diagnosed as an active case• Contacts who are TB skin test positive will be medically evaluated within 30 days after

the case was reported

*Follow state guidelines


þ

APPENDIX 3EXAMPLES OF EXPECTED OUTCOMES IN TB CASE MANAGEMENT

Activity: Treatment with anti-TB medication• Appropriate medication regimen completed in expected time frame (varies according to

patient’s condition)

Activity: Directly Observed Therapy (DOT)• Treatment completed• Patient maintains adherence rate that meets established objectives

Activity: Clinical monitoring of response to TB treatment• Status of sputum smears and cultures remain negative• Patient no longer demonstrates signs or symptoms of TB

Activity: Monitoring for adverse drug reactions• Potential adverse drug reactions were identified in a timely manner and if present,

adjustments were made to treatment plan

Activity: Adherence monitoring• Patient kept appointments with physician, nurse, and other team members• Patient did not miss DOT appointments• Barriers identified and issues addressed

Activity: Insight into TB disease process• Patient verbalizes an understanding of the TB disease process• Patient understands importance of following TB treatment regimen as evidenced by

adherence and completion of therapy• Patient cooperates with nurse and TB staff in TB control issues to prevent transmission

of disease

Activity: Treatment plan documented• Individualized care plan, developed in the early stages of treatment, is reviewed at

regular intervals and updated by team members as needed

Activity: Community health• Contacts will be identified, skin tested, and evaluated for treatment according to estab-

lished guidelines


APPENDIX 4ELEMENTS OF A TREATMENT PLAN FOR PATIENTS WITH TB (CDC, 1995)

I. Assignment of responsibility

A. Case manager (i.e., person assigned primary responsibility)

B. Clinical supervisor (e.g., nurse, physician, physician assistant)

C. Other caregivers (outreach worker, nurse, physician, physician assistant)

D. Person responsible for completing the contact investigation

II. Medical evaluation

A. Tests for initial evaluation (e.g., tuberculin skin test, chest radiograph, smear, culture,susceptibility tests, HIV test), including results of each test and date completed

B. Important medical history (e.g., previous treatment, other risk factors for drug resistance,known drug intolerance, and other medical problems)

C. Potential adverse reactions

1. Appropriate baseline laboratory tests to monitor toxicity (e.g., liver enzymes, visualacuity, color vision, complete blood count, audiogram, BUN, and creatinine), includingresults of each test and date completed

2. Potential drug interactions

D. Obstacles to adherence

III. TB treatment

A. Medications, including dosage, frequency, route, date started, and date to be completedfor each medication

B. Administration

1. Method (directly observed therapy or self-administered)

2. Site(s) for directly observed therapy

IV. Monitoring

A. Tests for response to therapy (e.g., chest radiograph, smear, and culture), includingplanned frequency of tests and results

B. Tests for toxicity, including planned frequency of tests and results


V. Adherence plan

A. Proposed interventions for obstacles to adherence

B. Plan for monitoring adherence

C. Incentives and enablers

VI. TB education

A. Person assigned for culturally appropriate education

B. Steps of education process and date to be completed

VII. Social services

A. Needs identified

B. Referrals, including date initiated and results

VIII. Follow-up plan

A. Parts of treatment plan to be carried out at TB clinic

B. Parts of treatment plan to be carried out at other sites and person(s) conducting activities


APPENDIX 5TB CASE MANAGEMENT GUIDELINES FOR PATIENTS WHO REQUIREHOSPITALIZATION DURING OUTPATIENT TB TREATMENT

It is the nurse case manager’s responsibility to monitor the patient’s progress while he/she is in thehospital, whether or not the hospitalization is related to TB. The case manager should communicateregularly with the hospital case manager, physicians, floor nurses, and infection-control nurses. Thefrequency with which the patient’s care and progress is monitored depends on the individual patientsituation, diagnoses, and other complications. It may be necessary for the nurse case manager to goto the hospital floor to actually review the patient’s medical record, see the patient, and discuss thecase with nurses and physicians. Prior authorization, however, should be obtained from the hospitalto allow the case manager access to hospital/patient records. Either a verbal understanding or writ-ten agreement identifying the case manager’s role during the patient’s hospitalization is important.Role clarification may need to occur with various disciplines within the hospital.

If management of the TB regimen becomes a problem during the patient’s hospitalization, the casemanager may need to discuss the situation with the physician who was treating the patient on anoutpatient basis, or the clinic’s medical director. Depending on the situation, physician-to-physicianmay be the most effective form of communication to resolve medical/treatment issues. An effectivecase manager utilizes the most capable existing resources in problem resolution.If the local health department, TB control, or clinic has ancillary personnel who function as hospitalliaison, the nurse case manager may elect to delegate the patient monitoring activities; however, itis important to give explicit instructions regarding delegated activities. Written or verbal reportsshould be given to the case manager on a timely basis so patient progress can be assessed.

Case management does not end when the TB patient is hospitalized, unless the patient hascompleted treatment or is no longer suspected of TB. Assessment, monitoring, and coordinationmust be continual. Working with the hospital staff to ensure the patient receives the appropriateTB regimen will assure uninterrupted TB treatment, allow appropriate discharge planning, thwartpatient problems, and increase the treatment completion in a timely manner.


The nurse case manager should ensure the following:

• The hospital treating physician has the medical information necessary to continue the patient’sTB treatment according to the outpatient plan

• The patient does not have an interruption of his/her TB treatment

• The TB drug regimen in the hospital is the same as prescribed by the clinic physician. Anychanges in the treatment regimen must be discussed with the treating clinic physician

• The ingestion of all TB medication is observed by an RN and documented in the patient’smedical record

• The doses of TB medication are not split during the day, but given all at once the same time.The exceptions to this would be patients who cannot tolerate taking all their medications atone time and medications which are difficult to tolerate, such as ethionamide and PAS. Theclinic physician treating the patient should clear all exceptions

• The patient’s TB drug regimen remains the same and is not changed by different doctorsduring the hospital stay

• Pulmonary TB cases have sputum collected, if infectious or thought to be infectious, at leastonce a week during the course of the hospitalization. The nurse case manager can give guid-ance about the bacteriologic findings and the necessity of sputum collection

• Appropriate discharge planning occurs

• There is a smooth transition from inpatient to outpatient care with no interruption in TB treat-ment

• The hospital medical record is available for the clinic physician at the first clinic visit followinghospitalization

APPENDIX 6 Patient _____________________________________

CHART REVIEW

Intermediate Outcomes Time frame Date(s) accomplished

TB contact interview 3 days

Contacts identified and tested 15 days

Medical evaluation of TST + contacts 30 days

Appropriate medication regimen at 1st visit/monthly

DOT arranged 24 hours

Testing/Screening Baseline and prn

• Blood

• Vision

• Hearing

• Sputum

• x-rays

• HIV

Sputum smear conversion 2-3 weeks

Sputum culture conversion 8-10 weeks

Clinical improvement monthly

• Subjective

• Objective

Patient Education

• Initiated at 1st visit

• Documented monthly

Appointments

• Physician follow up monthly

• DOT adherence monthly

• Referrals prn

Nursing care plan

• Initiated at 1st visit

• Documented monthly



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